Cardiac Imaging in Takotsubo Cardiomyopathy
A 62 year old woman presented with acute chest pain accompanied by widespread ST elevation on her ECG. An acute chest pain Sestamibi scan showed a moderate apical perfusion defect, but coronary angiography revealed normal coronary arteries with apical “ballooning” on the left ventriculogram. The following day a repeat rest Sestamibi scan showed almost complete resolution of the apical defect. A mild rise in troponin-T was noted but there was no CK rise. On Day 2 a hot spot scan showed mild pyrophosphate uptake in the antero-apical region on SPECT images. The patient made a full recovery, and follow-up Sestamibi imaging at 2 weeks showed completely normal myocardial perfusion, while an I-123 MIBG scan showed a persistent reduction in myocardial sympathetic function, most marked at the apex.
Takotsubo cardiomyopathy (also known as “broken heart syndrome”) is an increasingly recognised transient severe dysfunction of the apical ± mid-ventricular myocardium presenting clinically as an acute myocardial infarction but with normal coronary arteries and minimal rise in cardiac enzymes. The condition usually arises in post-menopausal women following severe emotional stress, and resolves spontaneously over days or weeks. It is thought to be due to abnormal catecholamine sensitivity resulting in microvascular dysfunction and severe myocardial ischaemia and stunning, but rarely infarction. This case demonstrates the severe transient perfusion defect, regional pyrophosphate uptake related to severe ischaemia, as well as the rapid recovery of perfusion and function but delay in normalisation of myocardial sympathetic function typical of this condition.